In workers’ compensation, it is not uncommon to come across a patient who has multiple claim numbers as the result of different injuries. Occasionally the claims or, more specifically, the body parts covered by the claims, overlap. We’ve received several questions about how to bill these claims so we’re clarifying this for everybody.
If a patient has multiple claims that cover the same body parts there should be two (or more) different claims on file with the claims adjuster. An example of this is a patient who has a lower R knee strain injury from 1/15/12, who then suffers a lower extremity crush injury on 7/14/14. Although the injury is to the same body part (R knee), the different dates of injury make this two separate injuries with two separate claim numbers.
In the above example, if a primary treating physician has authorization to treat both of these injuries then the provider should see the patient separately for each injury. This means creating two reports and seeing the the patient twice (two evaluation and management codes codes) -- once for each injury. The provider should not bill one report that covers both injuries, as this is not only difficult for claims administrators to pay but also makes it difficult to establish what treatment is being recommended for each injury individually.
A provider other than the primary treating physician should only treat the injury for which he or she has authorization. If the non-primary provider has authorization for multiple claims for a single patient then the provider should also see the patient once for each claim number and bill separately according to the particulars of each authorization.
If a patient has multiple claim numbers but the provider is only treating a body part covered by one claim number the provider should not bill using the additional claim numbers on the bill and report. Only the claim number for the body part being treated should be included. If there is ever any confusion over which claim number belongs to which injury we recommend calling the adjuster for clarification.
Occasionally a claims administrator will combine multiple claim numbers into one injury. In this case the provider should bill under the "master" claim number as provided by the claims administrator.. We have seen many providers forced to submit second bill reviews for bills that are complete and payable but have been denied for billing using the improper claim number.
When in doubt, call the adjuster!